Prescription opioid policy

A report which has just been released by the Royal Australasian College of Physicians has expressed major concern about the spiralling use of opioid medications - morphine-like drugs - for people with pain not due to cancer.

Transcript

Norman Swan: A report just released by the Royal Australasian College of Physicians has expressed major concern about the spiralling use of opioid medications, morphine-like drugs, for people with pain not due to cancer, so called non-malignant pain. The implication is that doctors may be treating such people inappropriately and therefore need some guidance.

One of the authors was Associate Professor Milton Cohen, a pain specialist at St Vincent's Hospital in Sydney.

Milton Cohen: This is chronic non-malignant pain estimated to affect one in five Australians directly.Not all those people become patients but one in five people represents a large proportion of the Australian population with pain present daily for three months.

Norman Swan: So give me a typical picture?

Milton Cohen: A typical sufferer from chronic low back pain whether that comes and goes or is there constantly over time. Any underlying disease or injury has either healed or is not directly treatable but the pain persists, not just the pain but the consequences of the pain on that person's ability to function in their family, in the workplace, in life generally.

Norman Swan: Let's just touch base with cancer-related pain for a moment because there is no controversy about opiates, the use of narcotic-like drugs, morphine-like drugs in people with cancer when they need it.

Milton Cohen: There's little controversy yes, opiates are accepted as the right if you like of people with cancer pain, the same arguments about whether or not you should use them just don't exist.

Norman Swan: People have said in that situation dependence or addiction is a very rare phenomenon, is that true?

Milton Cohen: In the context of cancer pain I think dependence as defined by needing the drug and having withdrawal if the drug is removed is a problem but it's one which can be overcome. Addiction as defined by a compulsive need to use the drug and other anti-social behaviours is uncommon.

Norman Swan: So the situation here is different so if somebody with what others might call a chronic pain syndrome where you've got chronic pain and sometimes there's an obvious cause for it and sometimes there isn't but it's very real pain and the question is what is the role of narcotics? What are the issues in relation to using morphine-like drugs in such people?

Milton Cohen: That question itself is the issue, what is the role of opioids especially long term in people with chronic low back pain for example. Maybe 15 or 20 years ago it was thought well we know that opioids work in acute pain and they work in cancer pain so why shouldn't they be made available to people with chronic non-cancer pain in whom other modalities of treatment haven't worked and so they started to be used. With initial encouraging results, such that specialists in pain medicine still feel that there is a role for those medications. But this has to be balanced by two things. Firstly there has been a rapid rise in the use of prescription opioids and the evidence for the true effectiveness of opioids long-term in non-cancer pain has been difficult to come by.

Norman Swan: So tell me the good, the bad and the ugly from your own clinical practice that you've seen. Tell me some stories where you've had a happy result and where somebody has been referred to you and you're very disturbed by what you've seen?

Milton Cohen: A good story is that many patients with chronic pain do in fact respond well to opioids in low dose taken over long periods of time and that reduces their pain. More importantly it increases their ability to function and the side effects are controlled or minimal.

Norman Swan: And that's things like using a morphine pump, not necessarily regular injections?

Milton Cohen: No, well I'm glad you mentioned that because using morphine or similar drugs other than orally is really not the way to go with chronic pain. We're talking about using oral medications, pumps, injections really are reserved for special situations, more in cancer pain as you mentioned. We are talking about oral use of opioids long-term, tablets.

Norman Swan: And what about patches?

Milton Cohen: Patches too, the recent availability of patches with the drug absorbed through the skin, almost like having a drug delivered continuously intravenously but absorbed through the skin.

Norman Swan: So that's the good, you've got some people who come in and for years they've been disabled by their chronic pain for whatever reason and low dose of these drugs helps. Tell me the bad stories you've seen.

Milton Cohen: The bad is that we often see people who have shown an initial response to these medications but in whom the dose requirement appears to be increasing regularly and is not accompanied by an improvement in their ability to function. And then side effects from these medications start to supervene. The other aspect of the bad is the increasing recognition of the role that emotional disorders, depression, anger, anxiety often play in chronic non-malignant pain and they may have been overlooked.

Norman Swan: So in other words a clinician, a doctor has taken the easy option which is using the narcotic rather than treating an underlying psychological problem which might relieve a lot of the distress associated with the pain?

Milton Cohen: Exactly, which speaks to the need for a comprehensive assessment of the person in chronic pain, not just focusing on that part of the body where the pain is.

Norman Swan: And have you come across many people who are addicted using your earlier description whose life is disrupted by the fact that they are on this and clearly they are behaving differently because they're on the narcotic?

Milton Cohen: In the context of being a pain doctor in pain clinic, in specially pain practice I don't think we see that many people who are frankly addicted. But the ugly side to which you referred earlier, is that there is increasing evidence that prescription opioids are being diverted and used by people for whom they're not prescribed.

Norman Swan: So in other words someone is crushing up the tablets and injecting them?

Milton Cohen: Either injecting them or selling them on.

Norman Swan: Do we know the statistics, how much they've gone up, how much the prescribing rates have gone up in this group of people?

Milton Cohen: Well we know that generally the usage of morphine in Australia has increased fortyfold since 1990 and the use of oxycodone, its cousin, has increased fourfold over the same period.

Norman Swan: Is this both in cancer patients and non-cancer patients?

Milton Cohen: Well this is just the usage of opioid analgesics so it could be.

Norman Swan: So some of that's good, people with cancer are getting good pain relief.

Milton Cohen: Yes, and some people who don't have cancer may well be getting good pain relief because of these opioids.

Norman Swan: But you don't know the margin where it's either inappropriate because something else should be treated or it's being diverted into the general market?

Milton Cohen: Precisely.

Norman Swan: Whilst you can have a moral angst about it being diverted is that a problem, isn't that just an inevitable part of prescribing opioids and we shouldn't get into a moral panic about it?

Milton Cohen: That's one way of looking at it but unsanctioned use of opioids, especially prescribed opioids is associated with morbidity, with mortality.

Norman Swan: So people get sick and die as a result?

Milton Cohen: People get sick and die and ongoing family disruptions, social disruption.

Norman Swan: So tell me what the conclusions were of this report?

Milton Cohen: The main conclusions were that we need more data to understand the prevalence of overall opioid prescription, how much of that is being prescribed appropriately, how much of it is being used in sanctioned ways, can we get a feel on the degree of diversion. Part of the reason for diversion I understand is an unmet need for opioid substitution therapy in people who are already dependent or addicted to these medications.

Norman Swan: So in other words a substitute for methadone?

Milton Cohen: Yes, then there is the great challenge of improving the management of people with chronic non-malignant pain generally.

Norman Swan: And presumably you don't even know how much of this is being prescribed in general practice versus people who set themselves up as pain specialists?

Milton Cohen: Oh precisely, we don't have the data information systems, we don't have for example real time on line information.

Norman Swan: Just in your practice are you getting a lot of people walking in the door who are already on morphine like drugs from the general practitioner?

Milton Cohen: Oh yes, quite common.

Norman Swan: So is that inappropriate?

Milton Cohen: It's not necessarily inappropriate.

Norman Swan: But they are not necessarily trained in the skills re quired of proper pain relief?

Milton Cohen: Precisely, I don't work in general practice but given the time constrains which I know are in general practice, it might be the easiest thing to do to prescribe a strong analgesic where by contrast what is required is a comprehensive assessment of that person, especially at the psycho-social level and looking at other conditions which might be contributing to their distress.

Norman Swan: Because when somebody goes to a pain clinic you're not just assessed by the doctor, you're assessed by the psychologist.

Milton Cohen: Physiotherapist, social worker if you're fortunate and other members.

Norman Swan: Of course if you live in the country here you don't have access to that so it is the GP. So are there guidelines for general practitioners to look after these people, to be fair to the GP, they might have tried Panadol, a bit of exercise, they know the story and then they are just desperate so they write out this script for oxycodone.

Milton Cohen: The problem is that there are various guidelines floating around but none of them is owned by any one group let alone all the groups. They are certainly not implemented and they are variable in what they say.

Norman Swan: And that's one of your recommendations.

Milton Cohen: One of the recommendations is to develop nationally developed and approved guidelines and then study their implementation.

Norman Swan: So if somebody is listening to this and there will be many who have chronic pain and might be a bit spooked by this, or wondering what sort of questions they should be asking their doctor having heard you, what are the questions you should ask as somebody with chronic pain of your physician or clinician?

Milton Cohen: I think one of the most important questions is, are you comfortable in treating me as someone who has chronic pain, because one of the great areas which we don't know much about are the attitudes of most doctors to chronic pain and to the use of opioids in particular.

Norman Swan: Which is quite a confronting question because many GPs will be quite uncomfortable about it because they feel hopeless on the part of the person, they don't know what to do next because they've tried everything and the person still has pain.

Milton Cohen: Which speaks of one of the great challenges arising out of this, how to improve their feeling of confidence and competence in that situation.

Norman Swan: Any other questions that should be asked, particularly if they're on something like oxycodone or an oral narcotic?

Milton Cohen: I guess the informed patient will say well what is the evidence that this is going to help me in the long term?

Norman Swan: And there's not much.

Milton Cohen: There's not much but we certainly know they help them in the short term but most studies don't go much beyond eight weeks.

Norman Swan: So Milton if somebody has chronic low back pain helped a bit by their oral narcotic therapy in the role of opioids but they are dependent, whenever they've tried to get off them they've clearly got a problem with them, what help is there available? Do we know how to unhook them from their opioids and get them onto something else?

Milton Cohen: Well this is where we really need the combined effort between the general practitioner, the pain specialist and the addiction medicine specialist. But certain principles certainly can be developed and promulgated that is looking carefully at what else is happening in that person's life, how are they spending their time, what beliefs are driving their behaviour. Whilst at the same time introducing a plan of gentle opioid reduction and maybe substituting with non-opioid analgesics looking more carefully at the role of anti-depressant medications to ease that transition. Other things like sleep hygiene, exercise, one way to capture this is you're treating this person with pain rather than treating the pain.

Norman Swan: Associate Professor Milton Cohen who co-authored that report which is available from the Royal Australasian College of Physicians in Sydney. I'm Norman Swan and you've been listening to the Health Report here on ABC Radio National.